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A Comparison of Primary vs Secondary Prevention

Steven A. Grover, MD, MPA, FRCPC; Steve Paquet, MSc; Carey Levinton, BSc; Louis Coupal, MSc; Hanna Zowall, MA

Arch Intern Med. 1998;158:655-662.

Objectives  To compare the potential years of life saved (YOLS) associated with risk factor modification in the primary and secondary prevention of cardiovascular disease (CVD).

Methods  The CVD life expectancy model estimates the risk of death due to coronary disease, stroke, and other causes based on the levels of independent risk factors (such as age, blood pressure, and blood lipid levels) found in the cohort of the Lipid Research Clinics. The model was validated by comparing its predictions with the observed fatal outcomes of 9 randomized clinical trials. We then estimated the YOLS associated with treating hyperlipidemia or hypertension among hypothetical patient groups with and without CVD at baseline. We defined high-risk patients as those with 3 risk factors (hyperlipidemia, cigarette smoking, and hypertension) and low-risk patients as those with isolated hypertension or hyperlipidemia.

Results  The fatal events predicted by the model were consistent with the clinical trial results. Among men and women with hyperlipidemia without CVD, the forecasted benefits of lipid therapy were substantially greater among high-risk groups vs low-risk groups (4.74-0.78 YOLS vs 2.50-0.25 YOLS, respectively). Among those with CVD, the forecasted benefits of treatment were similar for both high-risk and low-risk groups (4.65-0.65 YOLS vs 3.84-0.58 YOLS, respectively). The results for hypertension therapy also demonstrated greater benefits for high-risk vs low-risk patients undergoing primary prevention therapy (1.34-0.29 YOLS vs 0.85-0.13 YOLS, respectively), and the forecasted benefits in secondary prevention were similar (1.26-0.23 YOLS vs 1.00-0.23 YOLS, respectively).

Conclusions  The clinical approach to risk factor modification in primary prevention should be different from that in secondary prevention. The forecasted benefits of therapy among patients without CVD are greatest in the presence of other risk factors. Among those with CVD, the benefits of therapy are equivalent, thereby obviating the need to target high-risk patients.

From the Centre for the Analysis of Cost-Effective Care (Dr Grover, Mr Paquet, Mr Levinton, Mr Coupal, and Ms Zowall) and the Divisions of General Internal Medicine (Dr Grover) and Clinical Epidemiology (Dr Grover, Mr Paquet, Mr Levinton, Mr Coupal, and Ms Zowall), Montreal General Hospital; the Departments of Medicine and Epidemiology and Biostatistics (Dr Grover), McGill University, Montreal, Quebec.

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